Annual physical exam
an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the case below. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
CC: “Annual physical exam”
History of Present Illness (HPI): 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.
Current medication – denied
Allergies: no allergies to food or medications.
Family history: is very positive for diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General: no recent weight gains of losses, fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT):
CV: no chest discomfort or palpitations
Integument: history of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
PE: B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6
General: 23 year old male appears well developed and well nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress.
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, ornasopharynx clear, poor dentition – multiple carries.
Lungs: CTA AP&L
Cor: S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XII